- Email: [email protected]
Health Care Reform and Graduate Medical Education in Ophthalmology
Health Care Reform and Graduate Medical Education in Ophthalmology RICHARD K. PARRISH II, JEANETTE MLADENOVIC, AND STEVEN J. GEDDE
P
REDICTING HOW HEALTH REFORM MAY AFFECT THE
training of future ophthalmologists has never been more difficult. To better understand the factors that will affect tomorrow’s residents, it is critical to consider three key issues: the current funding for specialty and primary care programs, patient-driven choice for eye care, and new standards for patient care and education.
FUNDING FOR OPHTHALMOLOGY TRAINING OF THE FEDERAL PROGRAMS THAT SUPPORT ACCREDITA-
tion Council of Graduate Medical Education (ACGME)sponsored residencies, the Center for Medicare and Medicaid Services of the Health and Human Services (CMS/HHS) contributes the most. Medicare underwrote $9.5 billion for the training of 100 000 residents in 2008: $3 billion in direct graduate medical education payments to partially support resident salaries and $6.5 billion for indirect medical education, a calculated value based on the additional costs of patient care associated with training.1 Based on the San Francisco Ophthalmology Residency Match for years 2007 to 2009, approximately 1363 residents filled positions at 115 programs.2 Assuming ophthalmology represents 1.4% of all residents, the cost for their training is approximately $131 million, based on cost of the Medicare budget. This does not include funding supported by the Department of Defense or the Department of Veterans Affairs. The Balanced Budget Act of 1997 placed a cap on adding any new specialty residency positions and fixed the number of trainees at the 1996 level. Institutions that added new ophthalmology residents since then have done so at their own expense. Despite the cessation of new funding for specialty training, a recent movement has supported the growth of primary care trainees. The Resident Physician Shortage Reduction Act of 2009, which would have supported the training of 15 000 new residents in primary and specialty care programs, was not adopted. It would have added $12 billion to $15 billion to the Medicare program.3 Of the $787 billion stimulus package, Accepted for publication Oct 11, 2010. From the Bascom Palmer Eye Institute, Department of Ophthalmology (R.K.P., S.J.G.), and the Department of Medicine (J.M.), University of Miami Miller School of Medicine, Miami, Florida. Inquiries to Richard K. Parrish II, Anne Bates Leach Eye Hospital, 900 NW 17th St, Miami, FL 33136; e-mail: [email protected]
572
©
2011 BY
$500 million was earmarked for training programs in health professions, of which the National Health Service Corps (which recruits primary care providers) received $300 million.1 With the increasing incidence of age-related eye conditions in the US, such as cataract, macular degeneration, diabetic retinopathy, and glaucoma, lawmakers do not seem to understand the need for more ophthalmologists.4 Unless funding for expanded residency positions is approved, it seems unlikely that the current work force will be sufficient to meet the future needs. It is also ironic that providing visual-related health is not regarded as “primary” health care. Given the quality of life related to the maintenance of visual function and the economic burden of visual morbidity associated with systemic diseases, such as diabetic retinopathy, this position is unfounded.
PATIENT CHOICE FOR EYE CARE IN 2008, AN ESTIMATED 46.3 MILLION US INHABITANTS WERE
uninsured5,6 and 25 million were underinsured.5,7 The Patient Protection and Affordable Care Act (PPACA) (Pub L No.111-148) will expand health insurance coverage to approximately 34 million people by 2019;8 however, it will reduce the direct payments to hospitals for the care of uninsured and their Medicaid disproportionate share hospital (DSH) funding will decrease by $20 billion.5 Importantly, the PPACA will not provide for the care of undocumented immigrants.9 The PPACA will not alleviate the burden on safety net hospitals that currently provide the bulk of care for these patients. It is estimated that 23 million individuals will still remain uninsured even after the implementation of the PPACA. Of the 72 members of the National Association of Public Hospitals and Health Systems, 45 safety net hospitals receive DSH payments, including several public hospitals that are associated with large ophthalmology training programs, such as Grady Memorial Hospital, Ben Taub General Hospital, Los Angeles County Hospital, and Jackson Memorial Hospital. In fiscal year 2009, Miami’s Jackson Memorial Hospital incurred $619 million for all charity service costs, of which $268.2 million were unfunded, largely for the care of undocumented immigrants.10 In fiscal year 2010, the Anne Bates Leach Eye Hospital provided $22.9 million of unreimbursed eye care to Jackson patients through more than 29 000 encounters (personal communication, Michael Gittelman, September 1, 2010).
ELSEVIER INC. ALL
RIGHTS RESERVED.
0002-9394/$36.00 doi:10.1016/j.ajo.2010.10.017
The PPACA mandates eligible individuals to enroll for health insurance and creates penalties for those who do not purchase insurance. If the penalties for not purchasing insurance are less expensive than the cost of buying coverage, then currently uninsured patients may elect to remain without health insurance.5 The largest group that will receive health care coverage are an estimated 16 to 20 million Medicaid recipients with incomes up to 133% of the federal poverty level. Where these newly covered Medicaid patients decide to receive eye care could affect the financial support of safety net and teaching hospitals for funding resident training. If patients elect to go elsewhere, then a potential new revenue stream for currently uncompensated care would be diverted to outside providers. If newly funded patients choose to receive care at teaching hospitals, then revenues could increase. Entering newly eligible young adult patients into a stable eye care environment could lead to an increased detection and treatment of potentially blinding conditions, such as diabetic retinopathy and primary open-angle glaucoma, especially in high-risk groups. Currently many older patients with cataracts, macular degeneration, or glaucoma are Medicaid or Medicare beneficiaries and children with strabismus and amblyopia are recipients of Medicaid. It seems unlikely that either group would migrate to other providers; however, this remains an unknown.
MEETING NEW STANDARDS IN PATIENT CARE AND EDUCATION THE MEDICARE PAYMENT ADVISORY COMMISSION (MED-
PAC) recently recommended “to cut $3.5 billion in ‘extra payments’ from the indirect medical education adjustment and to use this amount to fund incentive payment to teaching institutions that would be contingent on their reaching new educational outcomes and standards.”1 The standards would mirror the ACGME competencies of practice-based learning and improvement, interpersonal communication skills, professionalism, and systems-based practice and integrate community-based and hospitalbased care. Funding of GME programs would be based on meeting these competency-based performance goals.11 How would this affect ophthalmology? Funding for training would depend on developing an integrated teambased visual health care. This would likely include health
care professionals, such as optometrists, general internists, endocrinologists, and low-vision counselors. Preparation for this expanded team approach will begin in medical school. Dr Nancy Andrews commented on the paradigm shift in education, “If we are going to solve our future health care needs, medical education will need to do more to prepare students for working collaboratively as members of health care teams. Ideally, students preparing for careers in the various health professions should interact through joint educational experiences that foster mutual respect and understanding. We need to let go of the traditional hierarchy and the view that a physician must always be the person in charge. We should invest in training programs and career development for non-MD practitioners.”12 How can we teach systems-based practice to ophthalmology residents in the future? Traditionally ophthalmology has thrived as one of many surgical subspecialty silos. Although most eye programs provide consultative inpatient service, the full integration of eye and general medical care in the community setting remains an unrealized opportunity. Residents at the Anne Bates Leach Eye Hospital do not have direct access to general medical records for patients who receive their care at the sponsoring institution, Jackson Memorial Hospital, including those with diabetic eye disease. It is likely that CMS, which pays for eye care of the elderly (Medicare) and indigent (Medicaid) by both ophthalmologists and optometrists, will demand an integrated “systems-based practice” approach in which both professions interact to provide cost-effective and competent care. Furthermore, future payments for patient care will be directed through accountable care organizations (ACO),13–15 including safety net hospitals, and bundled payments for services will be based on case management delivered by effective teams of physicians, nurses, and other health care professionals. Institutions that continue to teach ophthalmology residents in a manner isolated from primary medical care will no longer be financially rewarded. Advocating for enhanced funding for increased residency slots in ophthalmology may seem like an obvious solution; however, of greater importance is our reengineering of ophthalmology training as a preparation for practice in a very different health care environment in the near future. We should proactively provide leadership that will put ophthalmology at the center of the visual health care team.
PUBLICATION OF THIS ARTICLE WAS SUPPORTED BY FUNDING FROM RESEARCH TO PREVENT BLINDNESS, NEW YORK, NEW York; Strobis Glaucoma Foundation, Inc, Boca Raton, Florida; and National Eye Institute, Bethesda, Maryland. Dr Parrish has been a member of the Scientific Advisory Boards of Alimera Sciences, Inc; Allergan, Inc; Bausch & Lomb, Inc; Danube Pharmaceuticals, Inc; Glaukos Corporation; Merck & Co, Inc; Othera Pharmaceuticals, Inc; Pfizer, Inc; Sirion Therapeutics, Inc; and Vitreoretinal Technologies, Inc. Dr Parrish has received lecture fees from Alcon Laboratories, Inc, and Pfizer, Inc. Dr Gedde has received support from Abbott Medical Optics, Inc, Abbott Park, Illinois, for the Tube versus Trabeculectomy Study and the Primary Tube versus Trabeculectomy Study. Dr Gedde has received lecture fees from Lumenis, Inc, and is a consultant for Allergan, Inc. Involved in design of the study (R.K.P., J.M., S.J.G.); conduct of the study (R.K.P., J.M., S.J.G.); collection, management, analysis, and interpretation of the data (R.K.P., J.M., S.J.G.); and preparation, review, and approval of the manuscript (R.K.P., J.M., S.J.G.).
VOL. 151, NO. 4
EDITORIAL
573
REFERENCES 1. Iglehart JK. Health reform, primary care, and graduate medical education. New Engl J Med 2010;363(6):584 –590. 2. Ophthalmology Residency Match. Available at: http://www. sfmatch.org/residency/ophthalmology/about_match/match_ report.pdf. Accessed: August 23, 2010. 3. Robenieks A. Reform may worsen shortage: Med students numbers rise, residency slot stay flat. Mod Healthc 2009; 39(43):17. 4. Lee PP, Hoskins HD Jr, Parke DW III. Access to care – Eye care workforce considerations in 2020. Arch Ophthalmol 2007;125(3):406 – 410. 5. Connors EE, Gostin LO. Health care reform – a historic moment in US social policy. JAMA 2010;303(24):2521– 2522. 6. DeNavas-Walt C, Proctor BD, Smith JC. US Census Bureau. Current Population Reports. Income, Poverty, and Health Insurance Coverage in the United States. 2008. Washington, DC: US Government Printing Office, Economics and Statistics Administration; 2009. Available at: http://www. census.gov/prod/2009pubs/p60-236.pdf. Accessed: August 27, 2010. 7. Shoen C, et al. How many are underinsured? Trends among U.S. adults, 2003 and 2007. Health Aff (Millwood) 2008; 27(4):298 –309. 8. Office of the Actuary, Centers for Medicare & Medicaid Services. Forster R. Estimated financial effects of the “Patient
574
AMERICAN JOURNAL
9. 10.
11.
12. 13.
14.
15.
OF
Protection and Affordable Care Act” as amended. Available at: https://www.cms.gov/ActuarialStudies/Downloads/PPACA_ 2010-04-22.pdf. Accessed: August 27, 2010. Katz MH. Future of the safety net under health reform. JAMA 2010;304(6):679 – 680. Final report of the Miami-Dade County Grand Jury. Filed in the circuit court of the 11th Judicial Circuit of Florida in and for the country of Miami-Dade. August 5, 2010. Available at http://www.miamisao.com/publications/grand_jury/2000s/ gj2009f.pdf. Accessed November 2, 2010. Accreditation Council for Graduate Medical Education. Outcome Project general competencies. Available at: http:// www.acgme.org/outcome/comp/compMin.asp. Accessed: August 27, 2010. Andrews NC. Build it and hope that enough of them will come. J Clin Invest 2009;119(10):2860 –2861. McClellan MB. Reforming Provider Payment: Moving Toward Accountability for Quality and Value. Issue Brief. Accountable Care Organizations. March 2009. Available at: http://www.brookings.edu/⬃/media/Files/events/2009/0311_ aco/issuebriefacofinal.pdf. Accessed: August 28, 2010. Glass D, Stensland J. Accountable Care Organizations. Available at: www.medpac.gov/transcripts/0408_ACO_public_ pres.pdf. Accessed: August 28, 2010. Tallia AF, Amenta PS, Jones SK. Commentary: Academic health centers as accountable care organizations. Acad Med 2010;85(5):766 –767.
OPHTHALMOLOGY
APRIL
2011
Biosketch Jenny Mladenovic, MD, MBA, is Professor, Senior Associate Dean for GME, and Director of Research Education and Career Development at the University of Miami, Miller School of Medicine, Miami, Florida. She has been a member of the Board of Directors of the American Board of Internal Medicine, the ACGME RRC for Internal Medicine, and chaired the Examination Committees in Internal Medicine. Dr. Mladenovic, a hematologist by training, has directed a hematopoietic stem cell differentiation laboratory for 18 years.
VOL. 151, NO. 4
EDITORIAL
574.e1
P
REDICTING HOW HEALTH REFORM MAY AFFECT THE
training of future ophthalmologists has never been more difficult. To better understand the factors that will affect tomorrow’s residents, it is critical to consider three key issues: the current funding for specialty and primary care programs, patient-driven choice for eye care, and new standards for patient care and education.
FUNDING FOR OPHTHALMOLOGY TRAINING OF THE FEDERAL PROGRAMS THAT SUPPORT ACCREDITA-
tion Council of Graduate Medical Education (ACGME)sponsored residencies, the Center for Medicare and Medicaid Services of the Health and Human Services (CMS/HHS) contributes the most. Medicare underwrote $9.5 billion for the training of 100 000 residents in 2008: $3 billion in direct graduate medical education payments to partially support resident salaries and $6.5 billion for indirect medical education, a calculated value based on the additional costs of patient care associated with training.1 Based on the San Francisco Ophthalmology Residency Match for years 2007 to 2009, approximately 1363 residents filled positions at 115 programs.2 Assuming ophthalmology represents 1.4% of all residents, the cost for their training is approximately $131 million, based on cost of the Medicare budget. This does not include funding supported by the Department of Defense or the Department of Veterans Affairs. The Balanced Budget Act of 1997 placed a cap on adding any new specialty residency positions and fixed the number of trainees at the 1996 level. Institutions that added new ophthalmology residents since then have done so at their own expense. Despite the cessation of new funding for specialty training, a recent movement has supported the growth of primary care trainees. The Resident Physician Shortage Reduction Act of 2009, which would have supported the training of 15 000 new residents in primary and specialty care programs, was not adopted. It would have added $12 billion to $15 billion to the Medicare program.3 Of the $787 billion stimulus package, Accepted for publication Oct 11, 2010. From the Bascom Palmer Eye Institute, Department of Ophthalmology (R.K.P., S.J.G.), and the Department of Medicine (J.M.), University of Miami Miller School of Medicine, Miami, Florida. Inquiries to Richard K. Parrish II, Anne Bates Leach Eye Hospital, 900 NW 17th St, Miami, FL 33136; e-mail: [email protected]
572
©
2011 BY
$500 million was earmarked for training programs in health professions, of which the National Health Service Corps (which recruits primary care providers) received $300 million.1 With the increasing incidence of age-related eye conditions in the US, such as cataract, macular degeneration, diabetic retinopathy, and glaucoma, lawmakers do not seem to understand the need for more ophthalmologists.4 Unless funding for expanded residency positions is approved, it seems unlikely that the current work force will be sufficient to meet the future needs. It is also ironic that providing visual-related health is not regarded as “primary” health care. Given the quality of life related to the maintenance of visual function and the economic burden of visual morbidity associated with systemic diseases, such as diabetic retinopathy, this position is unfounded.
PATIENT CHOICE FOR EYE CARE IN 2008, AN ESTIMATED 46.3 MILLION US INHABITANTS WERE
uninsured5,6 and 25 million were underinsured.5,7 The Patient Protection and Affordable Care Act (PPACA) (Pub L No.111-148) will expand health insurance coverage to approximately 34 million people by 2019;8 however, it will reduce the direct payments to hospitals for the care of uninsured and their Medicaid disproportionate share hospital (DSH) funding will decrease by $20 billion.5 Importantly, the PPACA will not provide for the care of undocumented immigrants.9 The PPACA will not alleviate the burden on safety net hospitals that currently provide the bulk of care for these patients. It is estimated that 23 million individuals will still remain uninsured even after the implementation of the PPACA. Of the 72 members of the National Association of Public Hospitals and Health Systems, 45 safety net hospitals receive DSH payments, including several public hospitals that are associated with large ophthalmology training programs, such as Grady Memorial Hospital, Ben Taub General Hospital, Los Angeles County Hospital, and Jackson Memorial Hospital. In fiscal year 2009, Miami’s Jackson Memorial Hospital incurred $619 million for all charity service costs, of which $268.2 million were unfunded, largely for the care of undocumented immigrants.10 In fiscal year 2010, the Anne Bates Leach Eye Hospital provided $22.9 million of unreimbursed eye care to Jackson patients through more than 29 000 encounters (personal communication, Michael Gittelman, September 1, 2010).
ELSEVIER INC. ALL
RIGHTS RESERVED.
0002-9394/$36.00 doi:10.1016/j.ajo.2010.10.017
The PPACA mandates eligible individuals to enroll for health insurance and creates penalties for those who do not purchase insurance. If the penalties for not purchasing insurance are less expensive than the cost of buying coverage, then currently uninsured patients may elect to remain without health insurance.5 The largest group that will receive health care coverage are an estimated 16 to 20 million Medicaid recipients with incomes up to 133% of the federal poverty level. Where these newly covered Medicaid patients decide to receive eye care could affect the financial support of safety net and teaching hospitals for funding resident training. If patients elect to go elsewhere, then a potential new revenue stream for currently uncompensated care would be diverted to outside providers. If newly funded patients choose to receive care at teaching hospitals, then revenues could increase. Entering newly eligible young adult patients into a stable eye care environment could lead to an increased detection and treatment of potentially blinding conditions, such as diabetic retinopathy and primary open-angle glaucoma, especially in high-risk groups. Currently many older patients with cataracts, macular degeneration, or glaucoma are Medicaid or Medicare beneficiaries and children with strabismus and amblyopia are recipients of Medicaid. It seems unlikely that either group would migrate to other providers; however, this remains an unknown.
MEETING NEW STANDARDS IN PATIENT CARE AND EDUCATION THE MEDICARE PAYMENT ADVISORY COMMISSION (MED-
PAC) recently recommended “to cut $3.5 billion in ‘extra payments’ from the indirect medical education adjustment and to use this amount to fund incentive payment to teaching institutions that would be contingent on their reaching new educational outcomes and standards.”1 The standards would mirror the ACGME competencies of practice-based learning and improvement, interpersonal communication skills, professionalism, and systems-based practice and integrate community-based and hospitalbased care. Funding of GME programs would be based on meeting these competency-based performance goals.11 How would this affect ophthalmology? Funding for training would depend on developing an integrated teambased visual health care. This would likely include health
care professionals, such as optometrists, general internists, endocrinologists, and low-vision counselors. Preparation for this expanded team approach will begin in medical school. Dr Nancy Andrews commented on the paradigm shift in education, “If we are going to solve our future health care needs, medical education will need to do more to prepare students for working collaboratively as members of health care teams. Ideally, students preparing for careers in the various health professions should interact through joint educational experiences that foster mutual respect and understanding. We need to let go of the traditional hierarchy and the view that a physician must always be the person in charge. We should invest in training programs and career development for non-MD practitioners.”12 How can we teach systems-based practice to ophthalmology residents in the future? Traditionally ophthalmology has thrived as one of many surgical subspecialty silos. Although most eye programs provide consultative inpatient service, the full integration of eye and general medical care in the community setting remains an unrealized opportunity. Residents at the Anne Bates Leach Eye Hospital do not have direct access to general medical records for patients who receive their care at the sponsoring institution, Jackson Memorial Hospital, including those with diabetic eye disease. It is likely that CMS, which pays for eye care of the elderly (Medicare) and indigent (Medicaid) by both ophthalmologists and optometrists, will demand an integrated “systems-based practice” approach in which both professions interact to provide cost-effective and competent care. Furthermore, future payments for patient care will be directed through accountable care organizations (ACO),13–15 including safety net hospitals, and bundled payments for services will be based on case management delivered by effective teams of physicians, nurses, and other health care professionals. Institutions that continue to teach ophthalmology residents in a manner isolated from primary medical care will no longer be financially rewarded. Advocating for enhanced funding for increased residency slots in ophthalmology may seem like an obvious solution; however, of greater importance is our reengineering of ophthalmology training as a preparation for practice in a very different health care environment in the near future. We should proactively provide leadership that will put ophthalmology at the center of the visual health care team.
PUBLICATION OF THIS ARTICLE WAS SUPPORTED BY FUNDING FROM RESEARCH TO PREVENT BLINDNESS, NEW YORK, NEW York; Strobis Glaucoma Foundation, Inc, Boca Raton, Florida; and National Eye Institute, Bethesda, Maryland. Dr Parrish has been a member of the Scientific Advisory Boards of Alimera Sciences, Inc; Allergan, Inc; Bausch & Lomb, Inc; Danube Pharmaceuticals, Inc; Glaukos Corporation; Merck & Co, Inc; Othera Pharmaceuticals, Inc; Pfizer, Inc; Sirion Therapeutics, Inc; and Vitreoretinal Technologies, Inc. Dr Parrish has received lecture fees from Alcon Laboratories, Inc, and Pfizer, Inc. Dr Gedde has received support from Abbott Medical Optics, Inc, Abbott Park, Illinois, for the Tube versus Trabeculectomy Study and the Primary Tube versus Trabeculectomy Study. Dr Gedde has received lecture fees from Lumenis, Inc, and is a consultant for Allergan, Inc. Involved in design of the study (R.K.P., J.M., S.J.G.); conduct of the study (R.K.P., J.M., S.J.G.); collection, management, analysis, and interpretation of the data (R.K.P., J.M., S.J.G.); and preparation, review, and approval of the manuscript (R.K.P., J.M., S.J.G.).
VOL. 151, NO. 4
EDITORIAL
573
REFERENCES 1. Iglehart JK. Health reform, primary care, and graduate medical education. New Engl J Med 2010;363(6):584 –590. 2. Ophthalmology Residency Match. Available at: http://www. sfmatch.org/residency/ophthalmology/about_match/match_ report.pdf. Accessed: August 23, 2010. 3. Robenieks A. Reform may worsen shortage: Med students numbers rise, residency slot stay flat. Mod Healthc 2009; 39(43):17. 4. Lee PP, Hoskins HD Jr, Parke DW III. Access to care – Eye care workforce considerations in 2020. Arch Ophthalmol 2007;125(3):406 – 410. 5. Connors EE, Gostin LO. Health care reform – a historic moment in US social policy. JAMA 2010;303(24):2521– 2522. 6. DeNavas-Walt C, Proctor BD, Smith JC. US Census Bureau. Current Population Reports. Income, Poverty, and Health Insurance Coverage in the United States. 2008. Washington, DC: US Government Printing Office, Economics and Statistics Administration; 2009. Available at: http://www. census.gov/prod/2009pubs/p60-236.pdf. Accessed: August 27, 2010. 7. Shoen C, et al. How many are underinsured? Trends among U.S. adults, 2003 and 2007. Health Aff (Millwood) 2008; 27(4):298 –309. 8. Office of the Actuary, Centers for Medicare & Medicaid Services. Forster R. Estimated financial effects of the “Patient
574
AMERICAN JOURNAL
9. 10.
11.
12. 13.
14.
15.
OF
Protection and Affordable Care Act” as amended. Available at: https://www.cms.gov/ActuarialStudies/Downloads/PPACA_ 2010-04-22.pdf. Accessed: August 27, 2010. Katz MH. Future of the safety net under health reform. JAMA 2010;304(6):679 – 680. Final report of the Miami-Dade County Grand Jury. Filed in the circuit court of the 11th Judicial Circuit of Florida in and for the country of Miami-Dade. August 5, 2010. Available at http://www.miamisao.com/publications/grand_jury/2000s/ gj2009f.pdf. Accessed November 2, 2010. Accreditation Council for Graduate Medical Education. Outcome Project general competencies. Available at: http:// www.acgme.org/outcome/comp/compMin.asp. Accessed: August 27, 2010. Andrews NC. Build it and hope that enough of them will come. J Clin Invest 2009;119(10):2860 –2861. McClellan MB. Reforming Provider Payment: Moving Toward Accountability for Quality and Value. Issue Brief. Accountable Care Organizations. March 2009. Available at: http://www.brookings.edu/⬃/media/Files/events/2009/0311_ aco/issuebriefacofinal.pdf. Accessed: August 28, 2010. Glass D, Stensland J. Accountable Care Organizations. Available at: www.medpac.gov/transcripts/0408_ACO_public_ pres.pdf. Accessed: August 28, 2010. Tallia AF, Amenta PS, Jones SK. Commentary: Academic health centers as accountable care organizations. Acad Med 2010;85(5):766 –767.
OPHTHALMOLOGY
APRIL
2011
Biosketch Jenny Mladenovic, MD, MBA, is Professor, Senior Associate Dean for GME, and Director of Research Education and Career Development at the University of Miami, Miller School of Medicine, Miami, Florida. She has been a member of the Board of Directors of the American Board of Internal Medicine, the ACGME RRC for Internal Medicine, and chaired the Examination Committees in Internal Medicine. Dr. Mladenovic, a hematologist by training, has directed a hematopoietic stem cell differentiation laboratory for 18 years.
VOL. 151, NO. 4
EDITORIAL
574.e1